Ruminations by a non-academic general surgeon from the heart of the rust belt.

Sunday, December 13, 2009

Roll with those punches

I couldn't imagine being a doctor if I weren't a general surgeon. I knew after a week of my third year med school surgery rotation that I was destined to be a surgeon. Not destined in some phony, overblown Knights of King Arthur's Court sense, but destined in the realistic sense that I probably could not have enjoyed a long career in medicine doing anything else. No other specialty gave me the same heightened rush, the same zest for labor, the same excitement to get back to the hospital as soon as possible. In other words, no other specialty untapped my inchoate desire to tranform myself into a psychopathic workaholic. The idea of instantly alleviating a patient's suffering through invasive, mechanical intervention is an intoxicating elixir for the idealistic, type A young people that surgery tends to attract. You might call it a form of the "hero-complex"; we get off on marching into a room, diagnosing the problem and implementing a plan that will almost immediately lead to the reversal of the patient's physical maladies. It's a cool rush.

But there's a balancing counterpoise to the thrill of heroism. The things we do as surgeons to our patients are saddled with the weight of potential complications. An ICU nurse I know always asks me if I've "committed any surgery on people today". She's kidding of course (at least she better be!), but her comment is tinged with an element of truth. It's an act of controlled violence, surgery, and the consequences of that act are unpredictable. We do the best we can. Any surgeon will tell you that. There's never intent to harm a patient but once that scalpel slaps into our palm, we knowingly take on the burden of ultimately realizing a suboptimal outcome, an outcome that is a direct consequence of the maneuvers we are about to perform. That's life as a surgeon. One out of every 450 gallbladders we do will result in a major bile duct complication. 8-10% of all colorectal anastomoses we perform will leak, to varying degrees of severity. Wound infections will plague 10-15% of our laparotomy incisions. One to five out of every 100 inguinal hernia repairs we do will fail. 3% of those patients who undergo a Whipple for pancreatic cancer won't walk out of the hospital alive. About 5% of patients undergoing thyroid surgery will sustain an injury to the recurrent laryngeal nerve, with 20% of these patients suffering permanent voice damage. It's a minefield of cold hard statistics we navigate through each and every day.

I suppose most doctors deal with it, this sense of guilt that develops when something goes wrong. But I doubt anyone bears a greater burden than the surgeon. The internist (assuming not a careless ass) knows deep down in her heart that she prescribed all the correct medications, listened to her patient's complaints, diagnosed everything correctly. She can take some solace in the fact the patient was not entirely compliant, or had a horrible family history of cardiac disease, or maybe just developed some ridiculously rare metabolic disease that any doctor would have struggled to diagnose. It's not so easy to rationalize when you've just operated on someone and they don't do well. The second guessing never stops, incessantly tormenting your sleepless nights, heart racing, pacing the darkened halls of your house, desperately trying to visualize from the depths of memory the moment in time during the operation when you cut this or sutured that, searching to no avail for that instant when you could have done something better, another stitch, a different technique, another instrument, a sign or symptom you missed, a less risky maneuver, something, anything that would have prevented the current state of affairs, your patient in the ICU, frightened, worse off for the moment than she was before the surgery. We all have these cases. Every surgeon has complications and bad outcomes. The ones that deny it are either liars or they don't operate nearly enough.

I remember a patient specifically from my early career. Three weeks after I started as an attending surgeon I was called on a Sunday to see an elderly guy with a bad bowel obstruction. His white count was elevated and the nurse mentioned he was having a lot of pain so I came in to see him. He certainly had an acute abdomen and, in reviewing the CT scan, he had all the pathognomonic findings of a rare entity known as gallstone ileus (pneumobilia, calcified mass in the terminal ileum). What happens is, a large stone from the gallbladder over time erodes into the duodenum creating a wide mouthed fistula between the biliary and intestinal tracts. The stone drops into the duodenum and migrates slowly downstream. Eventually it wedges itself into a spot in the bowel where it can't go any further, usually in the terminal ileum or ileocecal valve. The result is a high grade small bowel obstruction. The only solution is an operation. Classic surgical dogma teaches that your agenda during the operation is simply to alleviate the bowel obstruction. Take out the stone, do a limited small bowel resection, whatever is necessary. As for the gallbladder and any other potential stones, you were supposed to defer that battle for another day. When I was a chief resident, however, I had read some newer literature suggesting that, in the event the patient was stable and didn't have too many other co-morbidities, it would be reasonable to pursue the source of the pathology (cholecystectomy) during the same operation. So I fixed the bowel obstruction and we'd only been under anesthesia for about twenty minutes. I noted that the patient seemed stable. His vitals were rock solid. His past medical history was pretty unremarkable; no heart disease to speak of. So I rearranged my retractors and took a look up near the liver. Everything seemed somewhat scarred down and distorted. Seconds after placing the retractor to heft the edge of the liver up out of the way, my heart sank as a rush of green bile filled the operative field. What happened was that a very small, fibrosed gallbladder had essentially fused itself to the lateral edge of the duodenum creating a contiguous lumen, and the force of the retractor lifting the liver tore this area open, leaving me with a substantial duodenal defect to deal with. The only safe option seemed to be duodenal exclusion (staple across the pylorus and redirect food through a gastrojejunostomy downstream). The tissues of the involved duodenum were worthless; pale and scarified and non-pliable. The sutures I placed didn't hold. I ended up closing the defect with a serosal patch from proximal jejunum. It was all I could do. I left a couple of JP drains and got out of Dodge.

Three days later, the inevitable occured; bile started accumulating in the JP drains. Not unexpected, at least the duodenal fistula was controlled with the external drains. He stabilized initially but after about a week he developed shortness of breath and the source was identified as a large pleural effusion on the right side. Likely this was a reactive effusion that developed secondary to the duodenal leak, or maybe it would have developed anyway, regardless of whether I explored the gallbladder or not. He was old. It was emergency surgery. Who knows. That's what I sometimes tell myself at least.

The man ended up going for a CT guided drainage of the effusion. Six hours later he was dead, succumbing to a rare complication of the drainage procedure.

I think about that case a lot, though not as much as before. Enough time has elapsed. But I don't want to forget it entirely. Flashes of images/thoughts flood my consciousness. Driving in to the hospital at breakneck speed, too late, already pronounced dead. The phone call I made to the eldest son, informing him that his father, who seemed to be doing so well, was suddenly dead. Filling out the death certificate. "Complications following recent surgery". What if. Why did you have to go poking around at the gallbladder? Case could've been much shorter. Should have been? Tried to do too much. To be a hero? Overestimated knowledge/capabilities? Error in judgment. What have I done? The loss. The son who must bury his father on a rainy Thursday while I have a nice uneventful dinner with my family. And having to wake up and do it all over again the next day. Calling for scalpel. As if nothing happened. The unobtainable forced forgetfulness of a surgeon. Shake it off. Roll with those punches. Do it again. Only do it better this time. Lights on. Another patient waits, asleep and vulnerable. They trust you. Do the right thing. A fresh start. Knife please.....

Your reasons for going into surgery are the same as for me going into Emergency Med.

What people don't understand is how difficult it is to go on to the rest of your day after something horrific happens.

Your bad surgery is equivalent to me going into a room with a sprained ankle after having a 45 minute resuscitation go bad or having to continue my day after losing a kid to SIDS. We don't get to go home and think about it and let the hurt wear off, we don't get 10 minutes before the next patient.

We live and work in a strange world where we're expected to be emotionless and go on like nothing happened. And we do, but it's incredibly hard, incredibly difficult.

it's hard to put a good spin on these tragedies. I guess we have to just honor these memories, grow/learn, and try and move ahead.

one case when I was in the very first few months of my radiology training has always stuck with me.

status post thoracentesis, another icu film of the dozens in the stack for that afternoon. my inexperienced eye didn't notice that the pleural effusion was a little bigger than the prior study. my attending didn't see it either.

the patient was found dead that night in her bed of a hemothorax.

I think of this case often when CT's start becoming pictures instead of patients.

your numbers seem awfully pessimistic. I've been consenting patients on the basis of 1/1500 for bile duct injury and 1-2% for RLN injury (the two common procedures I consent for) and these figures are borne out at the M&M.

i know this is a bit off at a tangent and besides the point, but when you said "3% of those patients who undergo a Whipple for pancreatic cancer won't walk out of the hospital alive" i couldn't help imagining them walking out as something other than alive.

sorry for the interlude. great post as we all have grown to expect from you.

I am a recent attending surgeon and have found that, as everyone who has went before tells you, complications are far harder to bear than expected. As a resident you can always subtly deflect blame in your mind to "the old man" either to pre-op care, in the or or post-op care. As the one calling the shots you have no one else to blame and so go to sleep at night questioning your every move. I like your statement of walking alone at night at home thinking about it. I feel an incredible burden on my soul with all of these difficult cases. My partners tell me the solution is alcohol! :) This is why I try not to operate on children-the thought of the complication born on little faces is too much.

Buckeye, I just finished a coveted ICU nursing intensive. It comforts me to know that some of you do truly worry. I've been told I have ability to sense trouble before it comes. You guys leave and mine is to monitor and wait. Sometimes this is a very lonely spot to be in. -SCNS

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